Ask a 100 psychotherapists how therapy works and you’ll get 100 different answers.  The truth is that no one knows for sure. Many theories are out there, each with loyal adherents.  Even though theories differ, the results are definitively that most of these differing perspectives produce similar results.  This phenomenon has been referred to as the “dodo bird phenomenon,” an Alice in Wonderland reference, meaning that all contestants receive prizes, no matter how different the theories and techniques.  Not only do a wide range of treatments yield favorable results, but it is also true that these treatments produce physical changes to people’s brains–not just their behavior, mind, and feelings of wellbeing.

If we assume our natural state is health, then we should be able to allow inner resources to take over once challenges have been clearly defined.

What makes things even more complicated is that a high percentage of therapists describe themselves as “integrative” in their approach, meaning that they mix and match different approaches according to their own view of how therapy can best promote positive change.  There is no reason to question whether pick-and-mix approaches to psychotherapy should differ substantially in their outcome. However, what does seem to be important is how much conviction your therapist has in whatever method they practice.

With this context in place, the following are a few of the ways that I believe therapy can help solve problems that other ways of changing one’s life don’t.

1. The therapeutic relationship:

Repeatedly, studies show that something about the relationship created between therapist and patient naturally promotes growth and greater feelings of wellbeing.  Repeatedly I hear patients communicate their assumption that psychotherapy works through catharsis; The therapist provides a safe place for place where patients can “get things out.” To the contrary, I interpret the repeated finding that the relationship creates change to mean that it is the give and take between client-clinician that does the work.  The directive received by patients to say whatever comes to mind as it comes to mind in particular therapies challenges people to bring more of themselves to a relationship. Merely the act of giving is only part of the equation. Receiving insights and observations from an attentive participant is an essential aspect of the therapeutic relationship.  Successful psychotherapy means both parties bringing their full awareness, attention, and participation to the fore is often much more than what people bring to their daily lives.  David Shapiro, a beloved mentor of mine describes moments of therapeutic impact in the client-therapist relationship far more succinctly with the phrase “making contact.”

2. Working through conflict:

In any relationship there is conflict, and the therapeutic relationship is no different.  “Ruptures” in a treatment can be extremely important in creating change if they are approached directly and “repaired,” rather than avoided.  Anxiety, which often at the heart of a presenting problem, stems from failing efforts to avoid some form of emotional distress. Confronting conflict, especially feelings of anger, set a precedent of approaching difficult emotions outside of therapy.  Moreover, conflict with a therapist is particularly useful since a good therapist is trained to 1. To listen and explore rather than react; and 2. Help understand the psychological reasons behind disproportionate anger, the origins of which lie outside the therapeutic relationship.

3. Improving capacity to express and tolerate emotions:

Anger that comes from conflict comes to mind as an especially difficult emotion for most people to tolerate.  The feeling of anger itself can feel both frightening and intoxicatingly powerful; however, past experiences, beliefs, and cultural taboos against anger specifically activate inhibitory mechanisms in our brain that turn a vital emotion into deadness.  Tolerating emotion means enduring the feeling itself, stomaching related emotions (e.g., guilt, shame, fear), and sufficiently regulating the emotion in order for it to motivate productive action. Some of us are great at using our anger to be productive, while struggling to sit with the vulnerability of sadness.  The opposite is often true. Many individuals are accustomed to receiving comfort in times of sadness and reproach when anger flares up as an oppositional force. The therapeutic relationship is one in which these tendencies can safely manifest, approached, discussed, and worked through. A good therapist should be well-versed in understanding and working with difficult emotions as well as using these emotions to enhance intimacy both in and outside of your psychotherapy experience.

4. Assuming a position of agency:

I have always found it astonishing how clients lament an upsetting pattern in their lives while simultaneously explaining that it occurred by a chance set of circumstances.  This amazement extends to my own way of denying persistent problems in therapy. If you are a passive observer to your problems, how on earth can you possibly prevent unnecessary repetitions? This type of defense can take many forms.  Suggesting depression is genetic, secondary to medical issues, entirely someone else’s fault, and/or due to an eroding social order are all different heads of the same hydra. While we may never know precisely how much our personalities (re)create painful scenarios, therapy seems to work best the more we own our role in unnecessary suffering.  No matter what your philosophical stance on free will is, the happiest people tend to be the one who feel the most effective in shaping a happy future.

5. Clearing obstacles impeding organic growth:

Some approaches to therapy work with the assumption that change requires an active, willful confrontation of behavior and thought patterns.  Others like my own, assume that once roadblocks to happiness have been identified, the best solutions can be found by the individual facing them. Solutions may be conscious or unconscious, but I believe each person must a solution that harmonizes with his or her own values, personality, and voice.  Irrational behavior is fairly easy to spot. The reasons behind acting irrationally (and continuing to do so) are not always obvious, nor are they easy to deconstruct. If we assume our natural state is health, then we should be able to allow inner resources to take over once challenges have been clearly defined.  With such an approach, I believe we achieve more satisfying outcomes and innoculate ourselves against falling into the same traps.

What I have outlined is far from an exhaustive or definitive list of ways that psychotherapy helps the modern individual through stubborn entanglements.  However, my aim in this brief and imperfect list of therapeutic factors in individual psychotherapy is to demystify what psychotherapists have in mind as they aspire to free others through cryptic conversation.